Despite the astronomical sums that the U.S. spends on maternity care, mortality rates for women and infants are significantly higher in America than in other wealthy countries. And because of a shortage of hospitals and ob-gyns, especially in rural areas, many women struggle to access proper care during pregnancy. Moreover, the rate of cesarean sections is exceedingly high at 32 percent—the World Health Organization considers the ideal rate to be around 10 percent—and 13 percent of women report feeling pressured by their providers to have the procedure.

Widespread adoption of midwife-directed care could alleviate all these problems. In many other developed countries, such as the U.K., France and Australia, midwifery is at least as common as care by obstetricians. In the U.S., certified midwives and nurse-midwives must hold a graduate degree from an institution accredited by the American College of Nurse-Midwives, and certified professional midwives must undergo at least two years of intensive training. This is designed to make midwives experts in normal physiological pregnancy and birth. Thus, for women with low-risk pregnancies who wish to deliver vaginally, it often makes sense to employ a midwife rather than a more costly surgeon. Yet only about 8 percent of U.S. births are attended by midwives.

The roots of America's aversion to midwifery go back to the late 1800s, when the advent of germ theory and anesthesia reduced much of the danger and discomfort associated with childbirth. The benefits of these technologies brought doctors to the forefront of maternity care and pushed midwives aside. Obstetricians helped to bar midwives from practicing in hospitals, which were now considered the safest birth settings. By the early 1960s midwifery was virtually obsolete.

It has made a comeback since then, with practitioners just as well trained as doctors to supervise uncomplicated deliveries. Studies show that midwife-attended births are as safe as physician-attended ones, and they are associated with lower rates of C-sections and other interventions that can be costly, risky and disruptive to the labor process. But midwifery still remains on the margins of maternity care in the U.S.

To bring it back into the mainstream, midwives must be fully integrated into the medical system. Some states currently refuse to recognize them as legitimate practitioners, and some severely limit what midwives are allowed to do, despite evidence that states with the most restrictive policies also have some of the highest rates of adverse birth outcomes, such as deaths of newborns. If midwives were allowed to work alongside other providers, patients would get the care advantages, and if difficulties arose, a woman whose home birth suddenly became complicated could be seamlessly transferred to a hospital.

Even when state laws are favorable, women who wish to work with midwives often face financial obstacles. Medicaid will cover all midwifery services, according to the Affordable Care Act, but the requirement does not extend to private insurers, many of whom lack in-network midwives or refuse to cover midwifery care at all. Half of planned nonhospital births are currently paid for by patients themselves, compared with just 3.4 percent of hospital births. Thus, a less expensive birth at home may paradoxically be out of reach for women who cannot afford to pay out of pocket. U.S. hospitals charge more than $13,000, on average, for an uncomplicated vaginal birth, whereas a similar midwife-attended birth outside of the hospital reduces that figure by at least half. Insurers would save money by embracing midwife-attended, nonhospital birth as a safe and inexpensive alternative.

A national shortage of birth centers further limits women's choices. These homelike settings are designed to support naturally laboring women with amenities such as warm baths and spacious beds and are consistently rated highly in surveys of patient satisfaction. Yet there are only around 350 existing freestanding birth centers in the entire nation, and nine states lack regulations for licensing such facilities. More government support for birth centers would help midwives meet a growing demand, which has already fueled an increase of 82 percent in centers since 2010.

Policy makers, providers and insurers all have good reasons to encourage a shift toward midwifery. The result will be more choices and better outcomes for mothers and babies.

This article was originally published with the title "Call the Midwife ... If You Can" in Scientific American 320, 2, 6 (February 2019)

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